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PUBLIC  HEALTH  VALUES 

A  FEW  MODERN 

SANITARY  FALLACIES 


BY 
DONALD  B.  ARMSTRONG,  M.  D. 


Address  delivered  at  the 

Conference  of  Mayors  and  Other  Officials 

of  the  Cities  of  New  York  State  at 

Auburn,  New  York 

June  5th,  1914 


Published  by  the  Bureau  of   Public  Health  and  Hygiene  of  the 

Department  of  Social  Welfare 

N.  Y.  Association  for  Improving  the  Condition  of  the  Poor 

Publication  No.  83 


PUBLIC  HEALTH  VALUES—  A  FEW  MODERN 
SANITARY  FALLACIES 

Donald  B.  Armstrong,  M.  D. 

Director  Department   of   Social   Welfare, 

N.  Y.  Association  for  Improving  the  Condition  of  the  Poor 

New  York  City  spends,  through  its  Health  Department,  about 
$120,000  a  year  on  the  inspection  of  its  milk  supply;  for  the 
year  19 12  the  city  appropriated,  for  the  purpose  of  keeping  its 
streets  clean,  over  $7,400,000.  The  first  expenditure  was  applied 
to  an  exceedingly  important  and  vital  phase  of  public  health 
work,  but  it  is  hard  to  show  that  the  $7,400,000  expended  for 
street  cleaning  and  waste  removal  was  of  much  direct  health 
value.  This  is  not  meant  to  be  in  any  respect  a  disparaging 
contrast;  it  is  not  intended  to  advocate  dirty  streets,  nor  to  urge 
the  expenditure  of  less  money  for  refuse  removal — probably 
more  should  be  spent  than  at  the  present  to  accomplish  worth- 
while results.  It  is  admitted  that  indirectly,  at  least,  such  fac- 
tors in  our  environment  are  of  more  or  less  importance  in  effect- 
ing our  general  welfare.  Even  though  it  were  of  no  importance 
from  the  point  of  view  of  health,  the  requirements  of  aestheticism 
and  of  decency  justify  the  larger  expenditure.  This  is  an  age 
in  which  the  mass  of  people  are  exceedingly  enthusiastic  and  to 
some  degree  hysterical  about  health.  By  those  at  all  familiar  with 
health  problems,  the  value  of  a  non-infected  milk  supply  is  ap- 
preciated. The  number  of  lives  sacrificed  to  the  cause  of  filthy 
milk  each  year  is  enormous.  Is  it  not  rather  strange  that  New 
York  City  should  spend  one-sixtieth  as  much  on  the  protection 
of  its  milk  supply  as  on  refuse  removal?  Is  it  not  in  some  part 
due  to  the  widespread  misunderstanding  of  the  relative  values 
of  the  factors  under  discussion?  Is  it  not  the  result  of  the  per- 
sistence in  the  minds  of  the  people  of  the  superstitions  arising 
from  the  barbarous   (though  quite  recent)  period  when  disease 


was  credited  to  emanations  from  garbage  dumps  and  filth  ac- 
cumulations? Is  it  not  due  in  some  part  to  an  under  estimation 
of  the  frequently  fatal  significance  of  the  tuberculosis  or  typhoid 
germ-laden,  though  often  innocent-appearing,  bottle  of  milk? 

Of  course  it  is  not  necessary  to  go  down  to  New  York  City 
for  examples  illustrative  of  this  method  of  health  and  pseudo 
health  expenditures.  Here  in  Auburn  in  1913,  the  health  ap- 
propriation was,  I  believe,  $12,320.  Of  this  $7,000  or  fifty-seven 
per  cent,  was  spent  on  garbage  removal,  leaving  only  $5,000  for 
such  measures  as  the  control  of  communicable  diseases,  anti- 
tuberculosis work,  infant  welfare  work,  etc.  Now  it  is  very 
pleasant  to  have  the  garbage  removed  and  it  is  not  very  decent 
to  have  it  lie  around,  but  the  removal  or  non-removal  of  it  has 
very  little  influence  on  our  morbidity  or  mortality  rates.  If  we 
have  here  only  $12,000  that  can  be  spent  on  health  work  then  it 
would  seem  wise  to  find  the  funds  necessary  for  garbage  re- 
moval somewhere  else  than  in  the  health  appropriation. 

It  is  becoming  widely  recognized  that  the  physical  welfare  of 
the  nation  is  fundamental  if  future  growth  along  any  line  is  not 
to  be  abortive.  The  people  are  fast  awakening  to  the  value  of 
public  health  work  and  to  the  necessity  for  spending  money  in 
order  to  get  results.  "Public  health  is  purchasable,"  and  so  is 
public  decency.  Both  are  worth  having;  both  are  expensive. 
In  any  case,  the  people  should  know  for  what  their  money  is 
spent  and  what  the  returns  are  likely  to  be.  An  expenditure  that 
is  made  for  the  preservation  of  decency  or  for  the  enforcement 
of  honest  methods,  should  not  be  disguised  as  a  health  measure. 

At  the  present  time  health  appropriations,  or  at  least  appro- 
priations for  work  done  under  the  direction  of  health  depart- 
ments, although  still  meagre,  are  on  the  increase,  and  now  is  an 
exceedingly  crucial  time  in  the  expenditure  of  these  public  funds. 
It  is  especially  necessary  to  spend  them  wisely  and  to  spend  them 
where  they  will  do  the  most  good.  There  are  thousands  of 
things  that  ought  to  be  done,  and  thousands  of  things  the  modern 
health  department  would  like  to  do.  It  is  not  possible  to  do 
them  all  at  once  and  since  there  must  be  a  selection  of  activities, 


it  is  essential  that  those  things  be  done  first  which  are  most 
tvorth  while ;  which  promise  the  biggest  returns ;  which  will  pre- 
vent the  most  sickness ;  which  will  act  most  strongly  as  a  health 
conserving  agent. 

The  aroused  interest  in  health  activities  and  the  resulting  in- 
crease in  the  amount  which  communities  are  willing  to  spend 
is  paralleled  by  an  increased  responsibility  resting  upon  those 
having  the  directing  authority  in  the  expenditure  of  health  funds. 
The  necessity  for  a  judicious  administration  is  bringing  to  a 
close  the  period  of  the  political  doctor.  There  is  a  demand  for 
trained  men,  and  several  schools  in  this  country  alone  are  doing 
what  they  can  to  meet  this  demand.  These  men,  who  are  making 
health  work  a  profession,  need  the  backing  of  an  intelligent 
public  opinion.  They  are  trained  to  know  the  most  important 
channels  of  health  work.  They  often  find  it  difficult  to  resist 
the  pressure  exerted  by  those  who  insist,  either  maliciously  or 
misunderstandingly,  on  the  misdirection  of  health  appropriations, 
to  ends  not  absolutely  worthless,  but  relatively  unimportant. 
There  is  a  striking  contrast  between  genuine  health  movements 
and  those  measures  which,  although  supported  by  arguments  not 
completely  fallacious  are,  many  of  them,  stimulated  by  a  not 
entirely  disinterested  propaganda,  and  to  say  the  least,  do  not 
encourage  the  truest  conservation  of  now  available  resources. 

It  is  possible  here  to  point  out  only  the  few  most  important 
conflicting  claims  upon  the  theoretical  health  budget.  The  dif- 
ference between  health  and  decency  has  been  touched  upon. 
The  two  fields  have  much  in  common.  Healthful  things  are 
always  decent;  decency  is  sometimes  healthful.  There  are  more 
significant  problems  than  this,  and  more  vital  ones,  to  be  found 
in  the  supposed  health  field.  It  is  true  that  in  most  progressive 
cities  street  cleaning  and  refuse  disposal  are  following  plumbing 
inspection,  nuisance  abatement,  and  other  allied  municipal  activ- 
ities out  of  the  health  department  and  into  other  municipal 
departments  where  they  more  logically  belong.  In  most  cities, 
however,  the  health  department  budget  still  includes  large  sums 
covering  other  activities,  the  wisdom  of  which,  as  health  measures. 


is  doubtful,  in  the  light  of  modern  knowledge  about  disease 
transmission  and  sickness  prevention. 

One  activity  somewhat  allied  to  refuse  removal  is  sanitary 
inspection.  In  the  year  191 1  the  Department  of  Health  of  the 
City  of  New  York  spent  $129,100.93  on  general  sanitary  inspec- 
tion. There  is  no  doubt  that  most  of  this  was  worth  while, 
particularly  that  part  which  goes  to  enforce  the  sanitary  code 
regarding  fly  breeding  and  fly  infecting  nuisances,  and  the  elimi- 
nation of  excrement  in  general.  There  is  also  no  doubt  that  a 
great  deal  of  relative  over-emphasis  is  placed  on  the  sanitary 
surveys,  sanitary  clean-ups,  etc.  During  the  same  year  New 
York  City  spent  $28,167.72  on  infant  milk  stations.  Since  the 
establishment  of  the  milk  stations  in  New  York  City  and  the 
broadening  out  of  the  Health  Department  infant  welfare  activ- 
ities the  death  rate  among  infants  under  one  year  (rate  per 
thousand  berths)  has  fallen  from  153.7  to  very  nearly  100. 
This  is  a  saving  of  thousands  of  lives — nearly  7,000  in  the  last 
year,  theoretically,  at  least — and  yet  in  contrast  to  the  amount 
of  money  which  accomplishes  this,  the  city  spends  a  much  larger 
sum  directed  in  part,  at  least,  to  the  cleaning  up  of  chicken 
coops,  the  removal  of  dead  dogs  or  the  abating  of  nuisances 
originating  largely  in  the  minds  of  uniformed  or  neurasthenic 
individuals.  Clean  chicken  coops,  clean  courtways  and  clean 
yards  are  desirable,  but  from  a  relative  standpoint,  are  they 
worth  what  they  cost?  Is  not  the  conflict  here  between  a  gen- 
eralized and  somewhat  hazy  expenditure  of  money,  the  health 
returns  from  which  are,  to  say  the  least,  doubtful,  and  on  the 
other  hand,  the  direction  of  the  funds  along  a  very  definite  and 
effective  health  line?  Apropos  of  this  point,  Dr.  Charles  V. 
Chapin,  Superintendent  of  Health,  Providence,  R.  I.,  may  be 
quoted*  as  follows : 

"In  New  England  most  of  the  garbage  is  fed  to  swine.  This 
usually  causes  some  nuisance,  but  ought  not  to  cause  much.  I 
have  never  learned  that  it  is  a  menace  to  health.    Yet  there  is  a 


*"How  Shall  We  Spend  the  Health  Appropriation?"  American 
Journal  of  Public  Health,  March,  1913. 


constant  pressure  on  our  cities  to  adopt  a  more  'sanitary'  method 
of  disposal  by  cremation  or  rendering.  This  usually  entails  a 
heavy  additional  expense.  If  the  new  method  is  sanitary  and 
there  is  plenty  of  money,  well  and  good.  But  if  children  still 
die  from  lack  of  antitoxin,  or  cannot  get  good  milk,  or  perish 
from  lack  of  doctors'  or  nurses'  care,  is  it  not  better  to  feed  the 
pigs  a  little  longer?" 

To  come  back  to  our  own  state,  the  City  of  Rochester  in  191 1 
appropriated  $67,494  for  health  work.  Out  of  this  $3,994  was 
spent  for  sanitary  inspection  while  a  sum  amounting  to  only 
$414  more  or  $4,408  was  devoted  to  milk  stations  which,  as  we 
know,  are  tremendous  factors  in  the  preservation  of  infant  life 
and  in  the  reduction  of  our  infant  and  general  mortality  rates. 
During  191 1,  as  we  have  stated  before,  New  York  City  spent 
S28,ooo  on  milk  stations,  so  that  comparatively  at  least,  the 
$4,408  spent  by  Rochester  in  this  field  is  a  very  excellent  show- 
ing. It  is  in  comparison  with  the  amount  spent  on  sanitary  in- 
spection, both  expenditures  coming  from  the  health  budget,  that 
the  sum  is  open  to  criticism.  The  irrationality  is  relative  rather 
than  absolute. 

The  public  is  eager  to  invest  money  in  health.  As  a  health 
investment  the  returns  from  sanitary  inspection,  plumbing  in- 
spection, food  inspection,  street  cleaning,  refuse  removal,  etc., 
will  be  meagre  and  in  the  end  are  likely  to  prove  unsatisfactory 
unless  we  have  reached  the  point  where  the  public  is  able  to 
make  value- judgments  in  health  matters  and  understands  the 
relative  significance  of  the  different  expenditures.  At  the  present 
time  such  returns  may  tend  to  destroy  popular  confidence  in  the 
health  movement  as  a  whole.  These  measures  are  in  strict  con- 
trast to  such  measures  of  real  vital  importance  as  the  elimination 
of  contagious  disease;  the  supplying  of  milk  free  from  tuber- 
culosis, typhoid,  dysentary  and  diphtheria;  the  manufacture  and 
administration  of  diphtheria  antitoxin,  smallpox  and  typhoid 
vaccines;  the  development  of  vital  statistics;  the  encouragement 
of  sanitary  research,  etc. 

In  the  preceding  paragraph,  food  inspection  has  been  included 
among  those  health  activities  which  are  of  comparatively  small 


importance  in  the  general  health  field.  On  account  of  the  present 
widespread  agitation  for  the  enactment  and  enforcement  of  food 
regulations,  this  problem  is  of  especial  interest.  The  present 
conflict  in  the  realm  of  sanitary  food  values  is  exceedingly  strenu- 
ous and  might  be  said  to  be  almost  ludicrous,  were  it  not  for  the 
immense  amount  of  energy  and  enthusiasm  which  the  struggle 
misdirects.  On  the  one  hand,  there  is  a  group  of  pseudo-health 
experts,  claiming  that  the  food  problem  is  by  far  the  most  im- 
portant phase  of  present  day  health  work.  These  poorly  trained 
or  misinformed  individuals  spend  their  energies  in  exaggerating 
the  dangers  from  food  adulteration  and  preservation.  They  ac- 
credit all  sorts  of  evil  results  consequent  to  the  cold  storage  of 
food  and  to  the  exposure  of  raw  foods  in  stores.  Health  depart- 
ments are  maliciously  incriminated  for  not  enforcing  the  law 
against  misbranding  and  against  short  weight.  As  a  matter  of 
fact,  chemical  analysis  has  shown  that  most  preservatives  are  only 
slightly,  if  at  all,  harmful.  They  may  have  impaired  the  health 
of  a  few  individuals ;  rarely  they  may  have  caused  a  death.  It  is 
perfectly  obvious  that  the  people  should  not  buy  adulterated,  mis- 
branded,  preserved,  short  weighed,  cold  storage,  or  any  other 
kind  of  food,  without  knowing  what  they  are  buying.  It  is  also 
just  as  obvious  that  compared  with  real  health  problems,  these 
things  are  of  very  slight  significance  from  a  health  point  of  view, 
and  in  theory,  at  least,  in  the  majority  of  instances  should  be 
handled  by  the  Department  of  Police. 

As  economic  problems,  these  food  questions  are  of  supreme  im- 
portance. As  health  measures,  is  any  city  justified  in  spending, 
out  of  the  health  budget,  one-third  as  much  on  food  inspection  as 
it  does  on  milk  inspection,  as  does  the  City  of  New  York?  (Permit 
me  here  to  apologize  for  the  frequent  references  to  New  York 
City.  It  is  in  that  field  that  I  am  working  at  present  and  am  con- 
sequently more  familiar  with  it.)  Here  again  it  is  not  the  amount 
that  is  objected  to, — it  is  the  proportion.  Undoubtedly  our  food 
supply  should  be  supervised,  and  it  will  cost  more  than  is  spent  at 
present  to  do  it  efficiently.  On  the  other  hand,  the  bad  effects  of 
food  preservatives  and  cold  storage  are  strikingly  insignificant  in 


contrast  to  the  results  of  a  combination  of  bad  milk  and  ignorant 
mothers.  During  the  summer  of  1910  these  two  were  very  impor- 
tant factors  in  the  deaths  of  54,266  babies  under  two  years  from 
diarrheal  disease  in  the  United  States,  9,740  of  which  were  New 
York  State  babies.  The  fatality  claims  of  even  the  wildest  food 
propagandist  are  insignificant  compared  with  these  losses.  At 
the  same  time  a  similar  relationship  probably  holds  true  for 
morbidity. 

Cold  storage  has  occupied  another  prominent  place  as  a  battle 
ground.  Great  amounts  of  food  have  been  destroyed,  largely 
because  of  the  length  of  the  time  in  storage.  Much  material 
in  storage  has  been  condemned  either  because  of  this  time  factor, 
which  in  reality  is  not  a  safe  criterion,  or  because  of  the  pres- 
ence of  the  "deadly"  colon  bacilli.  In  many  instances  the  highest 
scientific  authorities  had  declared  this  material  to  be  not  only 
harmless,  but  as  useful  for  food  as  it  had  ever  been.  The  colon 
bacillus,  except  by  a  few  of  the  food  "scientists,"  is  universally 
known  to  be  perfectly  harmless. 

Thus  the  food  protagonists  create  sanitary  straw  men.  The 
energy  they  waste  in  this  endeavor  is  equalled  only  by  the  energy 
expended  on  the  part  of  the  opposing  group  to  overthrow  these 
straw  men.  In  order  to  combat  the  wasteful  tendencies  of  the 
food  destroyers,  all  possible  arguments  are  brought  to  bear, 
showing  the  necessity  of  food  conservation  and  the  growing 
scarcity  of  public  food  supplies.  Cold  storage  is  praised  as  a 
tremendously  important  food  conserving  factor,  as  indeed  it 
would  be  if  the  industry  were  under  proper  governmental  con- 
trol, and  if  it  were  operated  as  a  public  service  and  not  for 
private  financial  gain.  This  is  a  point  which  does  not  seem  to 
occur  to  those  presumably  the  exponents  of  food  conservation. 
Neither  does  it  occur  to  them  when  emphazing  the  necessity  for 
avoiding  wastes  in  food  that  an  economic  and  social  method  of 
collecting,  transporting  and  distributing  food  would  be  a  thousand 
times  as  effective  in  counteracting  the  high  cost  of  living  as 
all  of  the  other  comparatively  petty  measures  sometimes  sug- 
gested. 


The  exciting  struggle  continues  over  minor  points  of  difference 
to  the  neglect  of  the  really  important  food  problems.  In  the 
first  place,  it  is  important  that  the  police  authorities  be  trained 
to  enforce  the  regulations  concerning  food  adulteration,  short 
weighing,  etc.  Eventually  this  burden  should  be  entirely  re- 
moved from  the  health  authorities.  In  the  second  place,  proper 
emphasis  should  be  placed  on  the  economic  importance  of  an 
efficient  and  reasonable  method  of  control  of  the  manufacture, 
collection,  distribution,  storage  and  sale  of  food.  This  problem 
is  of  immensely  more  importance  than  the  question  of  adulter- 
ation, misbranding  and  preserving.  Finally,  there  is  one  phase 
of  the  food  problem  which  is  of  genuine  sanitary  significance. 
It  is  undoubtedly  true  that  much  of  the  secondary  transmission 
of  disease  is  a  result  of  food  contamination.  This  contamination 
may  take  place  in  the  stores  and  public  places,  but  more  fre- 
quently occurs  in  the  homes.  The  theories  of  disease  emana- 
tions, of  the  aerial  transmission  of  disease,  and  of  infection  by 
fomites,  have  gone  by  the  board  in  epidemiology,  and  in  their 
place  sanitarians  have  become  interested  in  the  problems  of 
secondary  and  contact  infections.  The  chronic  disease  carrier 
has  become  a  factor  of  great  importance.  It  is  essential  that 
there  should  be  no  contact  between  the  disease  carrier  in  a  family 
and  the  food  of  the  other  members  of  the  family.  There  is 
danger  when  food  is  handled  by  any  person  in  the  incubation 
stage  of,  sick  with,  or  convalescing  from  any  contagious  disease. 
In  New  York  City,  for  instance,  there  is  no  doubt  that  a  large 
percentage  of  the  typhoid  cases  are  of  secondary  origin.  There 
is  also  no  doubt  that  many  of  these  cases  are  the  result  of  food 
infection.  In  a  recent  investigation  of  the  typhoid  situation  in 
New  York  City  it  was  found  that  in  seventy-five  per  cent,  of  the 
cases  the  same  person  in  the  family  nursed  the  patient  and  cooked 
the  food  for  the  rest  of  the  family.  This  suggests  a  food  problem 
of  real  importance,  and  one  which  can  be  met  only  by  education, 
more  efficient  means  of  isolation  and  quarantine,  a  more  compre- 
hensive system  of  public  health  nursing,  and  possibly  a  greater 
hospitalization  of  cases. 

10 


Another  illustration  of  this  same  discrepancy  is  illustrated  by 
the  expenditures  of  various  municipal  departments  for  plumbing 
inspection.  Although  the  more  enlightened  cities  have  relegated 
this  activity  to  other  departments,  the  great  majority  of  the  health 
budgets  have  to  cover  large  amounts  still  devoted  to  this  non- 
health  activity.     Let  us  take  a  few  local  examples : 

Albany  appropriated  in  1913,  $26,000  for  health  and  spent 
over  ten  per  cent,  of  it,  or  $2,800  for  plumbing  inspection. 

Syracuse  spends  $3,100  out  of  a  total  of  $80,000  on  plumbing 
inspection  and  at  the  same  time  maintains  only  two  milk  stations 
for  a  population  of  140,000  people. 

Elmira  appropriated  $6,000  for  health  and  spent  $1,200  for 
plumbing  inspection ;  at  the  same  time  Elmira  is  credited  with 
having  no  school  inspection.  This  $1,200  spent  on  pipes  and 
drains  would  be  immensely  more  effective  if  devoted  to  the  re- 
moval of  defects  in  human  plumbing,  particularly  the  adenoids 
and  tonsils  of  school  children.  It  is  a  contest  between  soil  pipes 
and  wind  pipes  with  the  odds  all  in  favor  of  the  non-human 
variety. 

Turning  to  the  more  vital  problem  of  communicable  disease, 
epidemics  of  diphtheria  or  other  contagious  affections  are  ob- 
served to  occur  from  time  to  time  among  school  children  and 
other  groups,  the  origin  of  which  is  sometimes  difficult  to  dis- 
cover. Recently  a  serious  epidemic  of  this  character  was  ac- 
credited to  the  pencils  which  were  collected  every  evening  and 
distributed  promiscuously  to  the  pupils  the  next  day.  A  few 
diphtheria  carriers  in  a  group  of  this  kind  (and  the  greater  pro- 
portion of  school  children  have  virulent  diphtheria  bacilli  in  their 
throats  or  nasal  passages  sometime  during  the  school  year),  might 
soon  sow  the  seed  for  a  widespread  outbreak.  In  any  case,  the 
damage  is  done  early  in  the  epidemic  and  the  infection  is  usually 
direct  from  child  to  child;  that  is,  contact  infection.  Very  fre- 
quently, however,  it  is  the  custom  to  disinfect  the  school  build- 
ing or  the  school  rooms  after  the  children  have  been  quarantined. 
This  is  certainly  "locking  the  barn  after  the  horse  is  stolen," 
particularly  in  the  light  of  the  fact  that  the  diphtheria  organism 


is  exceedingly  short-lived  and  rapidly  attenuated  when  compelled 
to  carry  on  a  saprophytic  existence.  This  brings  up  for  brief 
discussion  one  of  the  most  striking  and  expensive  modern  health 
fallacies,  namely,  disinfection  as  it  is  ordinarily  practiced.  No 
greater  farce  is  more  universally  perpetuated  than  the  expensive 
and  foolish  comedy  of  terminal  disinfection  of  the  utensils,  the 
homes  and  the  buildings  after  contagious  disease.  In  the  year 
1908  New  York  City  spent  $55,369.41  for  disinfection  and  fumi- 
gation, or  1.62  of  its  health  appropriation.  During  191 1  Roches- 
ter devoted  to  cleaning  and  disinfection  $2,580  or  1.26  of  its 
appropriation  for  that  year.  The  Health  Department  of  New 
York  annually  does  over  100,000  fumigations  and  disinfections.* 
The  folly  of  this  procedure,  as  ordinarily  carried  out,  is  fully 
known  to  everyone  at  all  familiar  with  the  facts.  There  is  little 
attempt  to  make  the  fumigation  really  effective,  though  when  act- 
ually necessary  it  can  be  made  so.  It  is  admitted  that  its  value  is 
purely  psychic.  It  is  done  to  comply  with  an  unintelligent  and 
uneducated  public  opinion  which  demands  it.  There  is  very  little 
evidence  to  show  that  with  the  exception  of  the  occurrence  of 
smallpox,  of  some  comparatively  rare  disease,  and  possibly  of  a 
fulminating  and  exceedingly  careless  case  of  tuberculosis,  the 
process  is  entirely  useless  and  exceedingly  wasteful.  More 
than  this,  it  is  a  dangerous  procedure,  because  it  perpetuates  a 
superstition  concerning  the  transmission  of  disease,  and  directs 
the  attention  of  the  family  and  of  the  people  at  large  away 
from  the  real  dangers.  An  organism  coming  directly  from  the 
body  of  a  person  suffering  with  a  contagious  disease  is  immensely 
more  dangerous  than  is  a  greatly  weakened  and  probably  dead 
organism  lying  on  a  chair  or  under  the  bureau  in  the  room  where 
the  patient  was  sick.  People  should  be  educated  about  the  dan- 
gers of  disease  transmission  and  contact  infection  during  the 


*The  amount  expended  for  this  purpose  in  New  York  City  in 
1913  was  $22,885.03;  during  the  fiscal  year  1910-1911  the  number 
of  fumigations  made  was  51,507;  the  number  of  disinfections 
58,55i- 

12 


sickness  of  the  patient.  A  great  deal  could  be  accomplished 
along  this  line  if  some  of  the  energy  and  money  which  is  now 
employed  in  terminal  disinfection  were  properly  directed.  The 
experience  in  Providence,  R.  I.,  has  shown  the  folly  of  disin- 
fection after  scarlet  fever  and  diphtheria,  in  some  periods  there 
being  an  actual  reduction  in  the  rate  of  recurrence  of  the  disease 
with  the  cessation  of  disinfection.  If  it  is  unnecessary  in  these 
diseases,  it  is  equally  useless  after  measles  and  whooping  cough. 
The  omission  of  disinfection  after  measles  in  New  York  City 
for  a  short  time  a  few  years  ago  was  without  effect  on  the 
prevalence  of  the  disease.  As  Dr.  Chapin,  of  Providence,  has 
said: 

"A  spark  in  the  dry  grass  should  be  stamped  out  at  any  cost, 
but  it  is  useless  to  waste  time  in  extinguishing  the  smouldering 
flames  left  here  and  there  as  the  line  of  fire  is  sweeping  across 
the  prairie." 

It  is  impossible  at  the  present  time  to  make  a  hard  and  fast 
distinction  between  things  which  are  of  great  importance  and 
those  which  are  of  no  importance  in  health  work.  It  may  be 
possible  to  suggest  a  classification,  incomplete  in  many  respects, 
made  up  of  two  groups,  into  the  first  of  which  would  be  placed 
the  things  of  greater  importance,  while  the  less  directly  im- 
portant measures  would  be  included  in  the  second  group.  This 
would  be  not  only  incomplete, — there  would  be  also  inevitable 
overlapping.  Much  of  the  work  that  would  be  included  in  such 
a  summary  should  be  done  at  the  present  time  by  other  depart- 
ments than  the  Health  Department,  such  as,  for  instance,  the 
Department  of  Education,  the  Department  of  Labor,  the  Depart- 
ment of  Public  Works,  or  the  Department  of  Police.  Such  a 
classification  for  the  average  New  York  State  city  might  be 
somewhat  as  follows : 

A.     Health  measures  of  prime  importance : 

i.     The   suppression   of   communicable    and   industrial 
disease. 


13 


2.  The  reduction  of  infant  mortality. 

3.  The  control  of  the  milk  and  water  supply. 

4.  The  medical  inspection  of  school  children. 

5.  The  study  of  contact  and  secondary  infections,  and 

the  control  of  disease  carriers. 

6.  The  control   of  hereditary  and    congenital   disease 

factors. 

7.  Birth,    death,    and   marriage    statistics,    and    book- 

keeping to  determine  the  value  as  a  life-conserv- 
ing force  of  any  expenditure  made. 

8.  Publicity  and  educational  work. 

9.  Sanitary  research. 

B.     Health  measures  of  secondary  or  of  indirect  importance: 

1.  The  control  of  housing  conditions  and  other  gen- 

eral environmental  factors. 

2.  The  inspection  of  foods  and  drugs. 

3.  The  handling  of  municipal  wastes. 

4.  The  suppression  of  nuisances. 

5.  Insect  and  rodent  elimination.* 

6.  Plumbing  inspection,  smoke  inspection,  etc. 

It  is  important  to  know  along  what  lines  the  health  appropria- 
tion should  be  directed.  It  is  important  to  have  some  idea  what 
returns  may  be  expected  from  a  certain  outlay.  It  is  even  more 
important  to  have  an  accurate  system  of  bookkeeping,  by  which 
it  is  possible  to  know  what  the  results  are  after  the  money  has 
been  spent  and  the  effort  made.  If  health  appropriations  are  to 
increase,  the  people  must  be  inspired  with  a  fundamental  and 
lasting  confidence  that  results  can  be  obtained  worthy  of  the 
cost.  If  the  people  at  large  are  to  have  any  reasonable  and  sound 
judgment  in  this  matter,  they  must  be  intelligently  informed  of 
the  true,  comparative  values  of  health  measures.  In  health  work, 
as  everywhere  else,  education  is  the  essential  prerequisite  to  sound 


*This  would  be  of  prime  importance  in  certain  communities 
where  malaria,  yellow  fever  (mosquitoes)  and  plague  (rats) 
exist.  It  is  probable  also  that  house  flies  are  of  considerable 
importance  in  the  transmission  of  diarrheal  diseases  of  infants. 


14 


judgment  concerning  relative  values.  Here,  as  always  in  a 
democracy,  we  must  have  confidence  in  the  significance  of  the 
greatest  epigram  in  the  history  of  the  world,  "know  ye  the  truth 
and  the  truth  shall  make  you  free." 


15 


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